Surveillance data from 2013 show high numbers of newly diagnosed hepatitis B and C cases notified across Europe. Chronic cases dominate across both diseases with a marked variation between countries: in 2013, 19 930 cases of hepatitis B virus infection were reported in 28 EU/EEA Member States, a crude rate of 4.4 per 100 000 population. 26 EU/ EEA Member States recorded 32 512 cases of hepatitis C resulting in a crude rate of 9.9 per 100 000 population.

1. Surveillance of hepatitis B and C
in the EU/EEA – 2013 data
Programme for HIV, STI and Viral Hepatitis B and C infections
July 2015
European Centre for Disease Prevention and Control

2. Surveillance of hepatitis B & C - Principles
• Surveillance programme coordinated by ECDC
• Data from 31 Member States are uploaded annually into
the European Surveillance System (TESSy)
 a purpose-built web-based system for data
collection
• Case-based and aggregate reporting possible
• Countries requested to follow the EU 2012 case
definitions, including acute and newly diagnosed chronic
infections
• Data collected on 33 variables
• Data validated by Member States

3. Surveillance of hepatitis B & C
- Objectives
Epidemiological objectives
1. To monitor the incidence and routes of transmission of newly diagnosed cases of hepatitis B and C in the general and vulnerable
populations
2. To monitor the prevalence of chronic hepatitis B and C virus infection to determine burden of infection (and estimate the proportion
undiagnosed) in the general and vulnerable populations
3. To monitor the proportion of chronic hepatitis B and C cases that are engaged in care (continuum of care)
4. To monitor the proportion of newly diagnosed chronic hepatitis B and C presenting late
5. To determine genotype and sequence distributions of newly acquired hepatitis B and hepatitis C viruses to better follow
transmission patterns, the emergence of resistance and vaccine escape mutants and potentially more virulent virus strains (priority on
hepatitis C infections)
6. To determine and describe the proportion of co-infections (HIV/HBV/HCV/HDV)
7. To determine the proportion of HCV re-infections (especially among key risk groups with high incidence e.g. PWIDs)

4. Surveillance of hepatitis B and C:
data completeness in 2013
0 20 40 60 80 100
Genotype
HIV status
Complications
Sex worker
Probable country of infection
Country of birth
Country of nationality
Transmission
Health care worker
Testing location
Outcome
Imported
StageHEP
Gender
Age
Data completeness (%)
Hepatitis B
Hepatitis C

5. Hepatitis B data: reporting countries and
case definitions
28 countries provided hepatitis B data in 2013
• Six countries could only provide data on acute cases
Case definitions varied:
• 18 countries used the EU 2012 case definition
• Six countries used the EU 2008/EU 2002 case
definitions
• Four countries used national case definitions
24 countries were able to classify cases as acute or chronic
according to the EU 2012 case definition

6. Rate of reported acute hepatitis B cases in
2013*
*Data for UK exclude Scotland

7. Rate of reported chronic hepatitis B cases
in 2013*
*Data for UK excludes Scotland

8. • In 2013, 19 101 cases* (4.4 cases per 100 000)
– Acute: 2 896 (15%)
– Chronic: 13 629 (71%)
– Unknown: 2 138 (11%)
• Variation in numbers and rates between countries
– Acute infections: from 0.1/100 000 in France and
Portugal to 4.3/100 000 in Latvia
– Chronic infections: from 0.1/100 000 in Romania to
15.5 in Sweden
Hepatitis B data: reported cases, rates and
stage of infection
*438 cases (2.3%) could not be classified by disease status due to incompatible format of the data provided

9. Rate of acute and chronic hepatitis B cases in
EU/EEA countries, 2006-2013
Source: country reports; Austria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece,
Hungary, Iceland, Ireland, Latvia, Lithuania, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia,
Slovenia, Spain, Sweden, United Kingdom (excluding Scotland).
0.1
1.0
10.0
2006 2007 2008 2009 2010 2011 2012 2013
Rateper100000
Logarithmic scale
Acute
Chronic

10. Hepatitis B data: distribution by age,
transmission and ‘imported’ status in 2013
• 35% of cases were aged between 25 and 34
– 15% of cases were aged under 25
• The male-to-female ratio: 1.5:1
• Transmission mode (21% complete):
- Acute: Heterosexual transmission (31%); nosocomial
(19%); injecting drug use (13%); MSM (9%)*
- Chronic: mother-to-child transmission (44%);
nosocomial (21%)*
• Migration variables poorly reported but 50% of cases with
complete information were classified as ‘imported’
- 92% of ‘imported’ infections are chronic*
*Cases classified as unknown were not included in the analyses

11. Hepatitis B by age and disease status:
rate of reported cases per 100 000, 2013
Source: Country reports; Austria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary,
Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Netherlands, Norway, Romania, Slovakia, Slovenia, Spain, Sweden,
United Kingdom (excluding Scotland).
0
5
10
15
20
25
30
<5 5–14 15–19 20–24 25–34 35–44 45–54 55–64 ≥65
Rateper100000
Age group (years)
Acute
Chronic

12. Reported transmission category for acute
and chronic hepatitis B cases, 2013
Source: Country reports; Austria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary,
Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Netherlands, Norway, Romania, Slovakia, Slovenia, Spain, Sweden,
United Kingdom (excluding Scotland).
0 10 20 30 40 50
Heterosexual transmission
Nosocomial (includes hospital, nursing home, etc.)
Injecting drug use
Men who have sex with men (MSM)
Non-occupational injuries (needle stick, bites, tattoos, piercings)
Other
Sexual transmission (not specified)
Household
Blood and blood products
Mother-to-child transmission
Needle-stick and other occupational exposure
Haemodialysis
Organ and tissues
Proportion of cases (%)
Transmissioncategory
Acute
Chronic

13. Hepatitis C data: reporting countries and
case definitions
26 countries provided hepatitis C data in 2013
• Four countries could only provide data on acute cases
Case definitions varied:
• 14 countries used the revised EU case definition
• Seven countries used the EU 2008 case definition
• Five countries used national case definitions
17 countries were able to classify cases as acute or chronic
according to the EU 2012 case definition

14. Hepatitis C data: reported cases, rates and
stage of infection
• In 2013, 31 513 hepatitis C cases* were notified
representing a rate of 9.6 cases per 100 000:
– 569 (2%) Acute
– 4 776 (15%) Chronic
– 23 230 (74%) Unknown**
• Variation in overall numbers and rates between countries
– Acute infections: rates from <0.1/100 000 in Portugal
and Greece to 2.6/100 000 in Latvia
– Chronic infections: rates from 0.1/100 000 in Romania
to 60.1/100 000 in Latvia
*2 938 cases (9%) could not be classified by disease status due to incompatible format of the data provided
**As acute hepatitis C is difficult to diagnose clinically or serologically, most ‘unknown’ cases are likely to be chronic infections.

15. Rate of all reported hepatitis C cases across
EU/EEA countries, 2006-2013
Source: country reports; Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland,
Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway,
Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, United Kingdom.
0
2
4
6
8
10
12
2006 2007 2008 2009 2010 2011 2012 2013
Rateper100000

16. Rate of reported hepatitis C cases in 2013
(including acute, chronic and unknown cases)*
*Countries included if their surveillance systems captured data on both acute and chronic cases..

17. Hepatitis C: distribution by age,
transmission and ‘imported’ status in 2013
• 54% of cases were aged between 25 and 44
– 9% were aged under 25
• The overall male-to-female ratio was 1.9:1
• Transmission mode (25% complete):
– Acute: Injecting drug use (39%); nosocomial (24%);
men who have sex with men (14%)*
– Chronic: Injecting drug use (78%); blood and blood
products (5%); unspecified sexual transmission
(4%)*
• 9% of cases with complete information were classified as
‘imported’*
*Cases classified as unknown were not included in the analyses

18. Rate of reported hepatitis C cases per 100 000 by age and
gender, 2013 (includes acute, chronic and unknown stage)
Source: Country reports: Austria, Cyprus, Czech Republic, Denmark, Estonia, Finland, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Portugal, Romania, Slovakia, Slovenia,
Sweden, United Kingdom.
0
5
10
15
20
25
30
35
<5 5–14 15–19 20–24 25–34 35–44 45–54 55–64 ≥65
Rateper100000
Age group (years)
Male
Female

19. Reported transmission category for acute
and chronic hepatitis C cases in 2013
Source: Country reports; Austria, Cyprus, Czech Republic, Denmark, Estonia, Finland, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Portugal, Romania, Slovakia, Slovenia,
Sweden, United Kingdom.
0 20 40 60 80 100
Injecting drug use
Blood and blood products
Sexual transmission (not specified)
Heterosexual transmission
Other
Nosocomial (includes hospital, nursing home, etc.)
Non-occupational injuries (needle stick, bites, tattoos, piercings)
Needle-stick and other occupational exposure
Mother-to-child transmission
Haemodialysis
Household
Men who have sex with men (MSM)
Organ and tissues
Proportion of cases (%)
Transmissioncategory
Acute
Chronic

20. Summary of key findings
• High numbers of newly diagnosed hepatitis B and C cases
notified across Europe
– Reported hepatitis C rate is more than twice the reported
hepatitis B rate
– Chronic cases dominate across both diseases
– Marked variation between countries
• Hepatitis B:
– a decrease in acute cases
– a rise in newly reported chronic infections
• Hepatitis C: strong geographical trend influenced by different
testing practices across Europe
• Transmission routes for hepatitis B differ from hepatitis C, and
for hepatitis B these routes vary by disease status
• Imported cases are significant, especially for hepatitis B

21. Key limitations of the data
• Different case definitions used by countries
• Some countries still only report acute hepatitis cases
• Difficulties with applying the EU 2012 case definitions
– Some countries use different case definitions
– High proportion of hepatitis C cases coded as unknown
• Data completeness low for certain variables:
– Genotype, complications, country of nationality, HCV
status (for HBV cases), HBV status (for HCV cases), HIV
status, sex worker, healthcare worker
• Under-reporting major issue reported by some countries
• Due to the largely asymptomatic nature of hepatitis
infections, data are strongly related to local testing practices

22. Acknowledgements
Thank you to the following groups and individuals:
• The European Hepatitis B and C Network and Coordination
Committee.
• EU/EEA country hepatitis and surveillance contact points.
• Surveillance colleagues at ECDC: Catalin Albu, Julien
Beauté, Denis Coulombier, Catia Cunha, Gaetan Guyodo,
Frantiska Hruba, Valentina Lazdina, Klaus Weist, Phillip
Zucs.
• Colleagues in the programme on HIV/AIDS, STI and Viral
Hepatitis B and C: Andrew Amato-Gauci, Erika Duffell,
Gianfranco Spiteri.

23. www.ecdc.europa.eu
Contact: stihivhep@ecdc.europa.eu